Open transcatheter aortic valve implantation on a degenerated bioprosthetic valve conduit

Abstract

The degeneration of bioprosthetic aortic Conduit with hemodynamic dysfunction mostly requires a re-do surgery, which is associated with an increased perioperative risk. Considering this, an open implantation of a transcatheter aortic bioprothesis (TAVI) after resection of the degenerated valve leaflets could be of great benefit, reducing cross-clamp and cardiopulmonary bypass duration, especially in combined surgery in high-risk patients. This is a case of a high-risk female (78 years, EuroScore 59%) treated with an open TAVI as an alternative to conventional valve or aortic conduit replacement for degenerative aortic valve due to endocarditis lente, 2 years following a bio-Bentall procedure.

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Esmolol, Antinociception, and Its Potential Opioid-Sparing Role in Routine Anesthesia Care

β-Adrenergic blockade is an important mechanism for reducing morbidity and mortality in patients with hypertension and heart failure. Esmolol has been used widely for its chronotropic and antihypertensive effects. However, there has been recent inquiry regarding perioperative esmolol use and nociceptive modulation. Conventional postoperative analgesic treatment has relied primarily on opioids, which present their own adverse effects and pharmacoepidemiologic repercussions. Esmolol, to date, has not shown any direct analgesic or anesthetic properties; however, recent studies suggest that esmolol may have antinociceptive and postoperative opioid-sparing effects. In this Daring Discourse narrative, we describe the role of esmolol in current perioperative β-blockade guidelines (related to noncardiac surgery), briefly describe studies supporting the antinociceptive effects of esmolol, propose mechanisms for esmolol antinociception, and forecast potential routine esmolol use intraoperatively (as part of a multimodal total intravenous anesthetic) and its effects on opioid sparing. The reading audience of regional anesthesiologists and acute pain medicine physicians is uniquely positioned to take a lead role in promulgating this care advance amid (i) the unwanted effects of the opioid epidemic and (ii) the uncertain notion of whether routine general anesthesia care (with fentanyl) may indirectly be contributing to the epidemic. Accepted for publication April 23, 2018. Address correspondence to: Brian A. Williams, MD, MBA, Department of Anesthesiology, University of Pittsburgh, Suite A-1305 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261 (e-mail: williamsba@anes.upmc.edu). The authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Nivolumab induced encephalopathy in a man with metastatic renal cell cancer: a case report

Great progress has recently been made in the treatment of metastatic renal cell carcinoma, including the introduction of nivolumab, an immune checkpoint inhibitor. Despite promising results, this treatment bri...

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Pineoblastoma in a child with 22q11.2 deletion syndrome

Description 

A 4-year-old girl with a history of chromosome 22q11.2 deletion syndrome presented to the emergency department with 2–3 weeks of worsening emesis. CT of the head revealed a large pineal region calcified tumour with associated hydrocephalus. Contrast-enhanced MRI of the brain and spine status postexternal ventricular drain placement confirmed a pineal tumour with diffuse metastatic leptomeningeal spinal spread (figure 1A,B). The child had a normal MRI of the brain 2 years prior (figure 1C) as work-up for her developmental delay. The diagnosis of 22q11.2 deletion syndrome was made by chromosomal microarray testing, which revealed a 2.5 MB deletion of 22q11.2 that included the TBX1 gene. Neuropathology on a subtotal resection showed clusters and sheets of tightly packed, small, blue cells with oval or slightly angulated nuclei and scant cytoplasm, consistent with a primitive neuroectodermal tumour. The tumour showed no loss of expression of INI...

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Coronary artery ectasia: a rare cause of acute coronary syndrome

Coronary artery ectasia (CAE) is defined as a localised or diffuse dilatation of coronary artery lumen more than 1.5 times that of an adjacent normal segment. CAE may present with or without functionally significant stenosis. Such patients may manifest with stable angina or with acute coronary syndrome. Ectasia may serve as a nidus for thrombus formation with likelihood of distal embolisation or it may lead to dissection or spasm. This condition presents a challenge for an interventionist. Should we intervene or manage it medically. We describe a case of CAE where all the vessels were diffusely ectatic with variable degree of stenosis. In brief we discuss the causes and management issues in ectasia.

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Uncommon cause of chest pain in a postoperative spinal patient

An 84-year-old woman with previous spinal operations including vertebroplasty and lumbar decompressions was admitted electively under the spinal team for right-sided L4/5 decompression for worsening back pain which she undergoes using a posterior approach. Postoperatively, she develops stabbing upper central chest pain and given unremarkable chest X-ray, ECG and cardiac troponin, she undergoes a CT pulmonary angiogram which shows a fracture of the upper part of sternum but no pulmonary embolism. There is no history of recent trauma and this is deemed to be secondary to prolonged spinal surgery in the prone position in a patient with osteopenic bones. To date, we have not come across a case of spontaneous sternal fracture as a complication of spinal surgery at our regional spinal unit. Most cases of sternal fractures are secondary to blunt anterior chest wall trauma with spontaneous fractures and stress fractures being rare.

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Spin-top-like encrustation of suprapubic cystostomy catheter: when proper counselling is all that it takes!

Description 

A 25-year-old man from a rural background and suffering from psychiatric illness had complaints of acute urinary retention 1 year ago for which trocar-guided suprapubic cystostomy (SPC) Foley catheter placement was done elsewhere after failed attempt of per-urethral catheterisation.

There was no history of haematuria, lithuria, catheterisation and endourological intervention in the past. On further eliciting the history, there was a retrograde urethrogram film taken 1 year back which revealed a short segment (1.0 cm) bulbar urethral stricture. He had undergone optical internal urethrotomy with Foley catheter placement (14F) under regional anaesthesia for his urethral stricture. Per-urethral catheter was removed after 7 days and he voided well with good urinary stream. He was sent back home and instructed to follow-up after 3 days for removal of SPC catheter and need of de-clamping SPC catheter in case of urinary retention again.

However, a thorough counselling about catheter's care and related complications was not...

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